AANS Neurosurgeon | Volume 28, Number 4, 2019


The Neurosurgeon in Sports Medicine

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While soccer is the most popular sport with over 200 million participants worldwide, other sports, particularly American football and ice hockey, have received much recent attention and have been singled out for their incidence of concussion. The truth of the matter is that essentially every athletic activity, especially those which have the potential for bodily collisions or head impact, can result in sports-related concussion (SRC). Each year, millions of athletes take part in football: 3 to 3.5 million kids play youth football; another 1.1 million play in high school; about 100,000 participate at the college level; and there are approximately 2,500 professional football players. It has been reported that up to 3.8 million people participating in organized or recreational athletic activities annually are affected by a SRC.

The initial diagnosis and management is often instituted on the field of play by coaches, athletic trainers and team physicians. SRCs are usually transient episodes of neurological dysfunction following a traumatic cranial impact, with most symptoms resolving in seven to 10 days; however, a small percentage of patients will suffer protracted symptoms after the event. The potential for season or career-ending brain injury, post-concussion syndrome or even the rare instance of long-term neurodegeneration may occur. Rarely, SRCs are associated with complications such as skull fractures, epidural or subdural hematomas, brain edema or spinal injury requiring neurosurgical evaluation.

Treating a Concussed Athlete
The 5th International Conference on Concussion is slated for Oct. 2016 in Berlin, but a general overview of the acute management of the concussed athlete was presented in the 4th International Conference on Concussion:

1. The player should be evaluated by a physician or other licensed health care provider on site using standard emergency management principles, and particular attention should be given to excluding a cervical spine injury.

2. The appropriate disposition of the player must be determined by the treating health care provider in a timely manner. If no health care provider is available, the player should be safely removed from practice or play and urgent referral to a physician arranged.

3. Once the first aid issues are addressed, then an assessment of the concussive injury should be made using the SCAT3 or other sideline assessment tools.

4. The player should not be left alone after the injury, and serial monitoring for deterioration is essential over the initial few hours after injury.

5. A player with a diagnosed concussion should not be allowed to return to play on the day of injury.

General management of SRCs focuses on mental and physical rest until an athlete is symptom free. Following this clinical improvement, a graduated increase in physical activity is utilized before an individual may return to play. Each stage of the graduated increase is expected to take 24 hours, and the athlete must remain asymptomatic to qualify and proceed to the next tier of activity. If any symptoms return, the athlete should curtail physical activity, rest for 24 hours and then try again to return to the previous activity level. They may return to play once asymptomatic. If symptoms persist or if athletes have a history of multiple concussion or mood disorders, a referral to a concussion specialist is warranted. It is often the best practice to evaluate athletes with a suspected SRC in a formal clinical setting before clearing them to return to the field of play.

Technological Advances
New technology has improved our medical capabilities and is changing the way physicians evaluate and treat athletes who suffer a concussion. Advanced imaging techniques such as diffusion tensor imaging or functional MRI, neuropsychological evaluation, balance assessment and a detailed understanding of the complex pathophysiological processes underlying SRCs illuminate how athletes are affected acutely and long-term. It is hoped that these advances will allow a more accurate estimation of when an athlete is truly safe to return to play, decrease the risk of secondary impact injuries and eventually provide avenues for therapeutic strategies targeting the complex biochemical cascade that results from a traumatic injury to the brain.

The issue of concussions has become one of the hottest subjects in sports. What constitutes a dangerous hit to the head? There has been the specter that concussions and their potential for long-term effects could lead to many sports, especially those with the potential for head contact, failing to be enjoyed by future generations. Parents have questioned whether sports with frequent head contact are appropriate for their children. Rather than signaling the demise of contact sports, and especially football, the heightened awareness of concussions should be interpreted as the turning point that has made sports — including youth sports — safer than ever before. Innumerable physical fitness, mental health and developmental benefits are derived from sports participation. 

From the National Football League (NFL) and National Hockey League (NHL), the National Collegiate Athletic Association (NCAA) and National Federation of High Schools (NFHS), to youth sports, numerous changes have been made to reduce gratuitous and unnecessary head contacts. In my role as the chairman of the Medical Advisory Committee of the Pop Warner Football League, the nation’s oldest and largest youth football association, we have strived to make significant changes and in 2012, discontinued  head contact in practice drills. This year, for the younger age groups, we eliminated the kickoff. An independent organization, Datalys, recently published a study which showed that by using Pop Warner Football rules against unnecessary contact and USA Football’s “Heads Up” education program, concussion rates are now down to less than 1 percent of players annually.

As neurosurgeons and concussion experts, we have exceptional knowledge which allows us to properly manage and treat those with sports concussions, and we should take an active role in athletic activities in our local schools and communities. While the possibility of a severe intracranial injury is ever-present, it is unusual that our surgical capabilities would be needed. Instead, the neurosurgeon is often involved in ruling out serious injury, in caring for those players with post-concussion syndrome and with return-to-play decisions, which are highly individualized and require consideration of numerous factors. Knowing the local resources and formulating a concussion health care team approach for the injured athlete is recommended. Together with our neurosurgeon colleagues, physicians, coaches, athletic trainers, school administrators and parents, our goal should be to change the focus from fear and reluctance to one of enjoying sports and making them safer for athletes at all levels of participation.

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